Organization
SOUTHEAST MISSOURI HEALTH NETWORK
Active
Parent organization
SOUTHEAST MISSOURI HEALTH NETWORK
Other names
PORTAGEVILLE FAMILY CLINIC
Organization subpart
Yes
Provider details
NPI number
Legal business name
SOUTHEAST MISSOURI HEALTH NETWORK
Authorized official
CHERYL A WHITE (CHIEF EXECUTIVE OFFICER)
(573) 748-2404
Entity
Organization
Contact information
Practice address
314 E MAIN ST, PORTAGEVILLE, MO 63873-1616
(573) 379-5929
(573) 379-5912
Mailing address
311 MAIN ST, P.O. BOX 400, NEW MADRID, MO 63869-1942
(573) 748-2404
(573) 748-8929
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010626
GROUP PTAN
MO
05
—
503973901
—
MO
Enumeration date
04/25/2007
Last updated
03/07/2011
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